Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> ENVIRONM TA EALT PERMIT PUMP&WELL �. <br /> (COMPLETE IN TRIPLIC E) '7S 7ALITT <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> made in compliance with 5aRJoaquin County Ordinance No. 1862 and the rules and Cregulations of the San oa Local Health District. <br /> t Exact Site Address _!`_ �Fr;�.� 1 City/Town <br /> 04 <br /> Owner's Name �7^ y � � <br /> Address I � Phone <br /> p` d City. <br /> Contractor's Name License Business Phone ' <br /> T Contractor's Address / �j _ Emergency Phone 5f rig 4 _ <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes v' No <br /> TYPE OF WORK (CHECK); NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT Pl--'OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ d <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank ` sewer Lines Pit Privy <br /> Sewage Disposal Field �' Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL' Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY y Type of Grout I <br /> ❑ DISPOSAL ❑ OTHER - Other Information <br /> ❑ GEOPHYSICAL ,� Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> a Type of Pump' H.P, <br /> PUMP REPLACEMENT: <br /> 1:1 State Work Done <br /> PUMP REPAIR: ❑ State Work'Done <br /> DESTRUCTION OF WELL;. Well Diameter- !f <br /> f , Approximate Depth OD <br /> -- - -- - Describ Material_and_Procedure_ a )w/ /2,+e A .52)! <br /> I hereby certify that I have prepared this application and,that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. i <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this — l <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." Q� <br /> I wil all or a Grou spection prior to grouting and a final inspection. <br /> Signed X Title: Date: 411_ 0— <br /> (Draw Plot Plan on Rever e-Side) l <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> 1 <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection A Phase III Final Inspection <br /> Inspection By _ Date, .lnt pection By ,Date / u'__�/ <br /> Fee Is Due: ❑ ANNUALLY ❑.PER UNIT ❑ PER SITE ❑ EACH ❑-January 1 $Received By January 31 `' ❑ July 1 &Received By July 31 <br /> B " $ REMIT <br /> BILLING REMITTANCE <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT OUE CHECKED <br /> AMOUNT <br /> FEE , .E` el � 0� 9 <br /> LESS ` <br /> PRORATION <br /> PLUS 1 <br /> PENALTY <br /> OTHER <br /> I <br /> OTHER <br /> an-- <br /> � � ys . slsl;�� T <br /> Received by Date Receipt No. Permit No. <br /> Issi.fance0ate Mailed Delivered <br /> 1 <br /> • APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES ,- 1607&HA2ELTONAVE.,P.O.Boy 2404 STOGKTON,CA 95201 <br />